Accreditation for general practice

The achievement of accreditation demonstrates your practice's commitment to quality assurance, continuous improvement, and the provision of safe and quality healthcare to your patients.

General practice accreditation is a voluntary process in Australia.

However, accreditation is a mandatory criterion for practices wishing to participate in the Practice Incentives Program (PIP), or wanting to become a training provider in the Australian General Practice Training Program.

Accreditation in Australia is managed under the National General Practice Accreditation (NGPA) Scheme.

This Scheme is the work of the Australian Commission on Safety and Quality in Health Care (the Commission), and aligns GP accreditation to the Australian Health Service Safety and Quality Accreditation Scheme. The NGPA Scheme provides greater choice for practices seeking accreditation, improves support programs for implementation of accreditation and, in the future, will allow for the collection and reporting of accreditation performance data to allow practices to benchmark themselves.

Practices are assessed against the Royal Australian College of General Practitioners Standards for general practices, currently in its 5th edition.

The Standards were developed with the purpose of protecting patients from harm by improving the quality and safety of health care. The Standards support general practices in identifying and addressing gaps in their systems and processes.

Accreditation Fact Sheets & Resources

RACGP Practice Standards & Resources
Overview of the National General Practice Accreditation Scheme (Resource)
General Practice Hand Hygiene (Resource)
General Practice Ethical Dilemmas Policy and Procedure (Template)

General Practice Accreditation Frequently Asked Questions

Is my practice eligible for accreditation?

Practices seeking accreditation against the Standards for general practices need to meet three core criteria:

The practice or health service operates within the model of general practice described in the RACGP's definition of a general practice
GP services a predominantly of a general practice nature
The practice or health service is capable of meeting all mandatory indicators in the Standards

Practices may apply to an accreditation agency for accreditation, but may be asked to demonstrate how they meet these criteria if the agency cannot easily confirm that the applicant is eligible for general practice accreditation.

Who can provide accreditation to my practice?

if your practice is seeking accreditation as part of its eligibility to participate in the Practice Incentives Program, it must be accredited by an agency approved under the NGPA Scheme.

As at 1 January 2019, the Commission has approved three agencies to assess practices against the Standards:

Practices seeking accreditation should make enquiries with the approved agencies to determine the cost, expectations and program for accreditation provided by each agency.

How often will my practice have to undergo accreditation?

Accreditation is a three year cycle, meaning that a practice with no unusual circumstances (such as a relocation, or identification of significant risk) will have an onsite assessment once every three years.

In order to maintain accreditation, your practice must be reassessed and found compliant prior to your existing accreditation expiry date.

When should I register for accreditation?

There are two primary registration processes for practices seeking accreditation: one for practices seeking accreditation for the first time, and one for practices seeking re-accreditation.

Practices seeking accreditation for the first time

If your practice is planning to undergo its first accreditation, you can register whenever you feel your practice is ready to commence its preparation. If you have established a new practice, it is worthwhile reviewing the Standards and understanding the intent and requirements prior to making the decision to register for accreditation. Your practice will have twelve months from registration to complete the full accreditation process, including onsite assessment, so before you register, ensure you are ready to progress through accreditation within that timeframe. This is particularly important if you are registering for the PIP at the same time: PIP maintains strict limits around the twelve-month timeframe, and if your practice is not accredited within twelve months, your PIP eligiblity may be impacted.

Practices seeking re-accreditation

If your practice is already accredited, you should consider registering for your next round of accreditation twelve months prior to your existing accreditation expiry date (for example, if your accreditation expires in November 2020, register for your next round in November 2019). Twelve months is the ideal timeframe in which to prepare your practice for its onsite assessment, and complete the accreditation program delivered by your preferred agency. Accreditation agencies will usually contact their clients to remind them that it is time to register for the next round of accreditation.

Accreditation agencies will do their best to accommodate their clients, but there may come a time after which they can no longer guarantee the accreditation process can be finalised within the time available. Remember that if you cannot achieve accreditation (or re-accreditation) within the available time, you risk eligibility for programs that include accreditation as a mandatory criterion.

What happens after I register for accreditation?

For practices undertaking their first round of accreditation, you will be provided with a registration certificate that you can use as evidence of registration when applying to join the Practice Incentives Program. Practices seeking re-accreditation are not provided with a registration certificate as they already have an existing certificate of accreditation.

The next steps in the process will depend on the accreditation provider your practice has selected. The accreditation program may include a self-assessment, a desktop audit, or other preliminary processes that help prepare you for your onsite assessment (survey visit). Our Primary Health Liaisons can help you in this initial stage of preparation.

How much does accreditation cost?

The cost of accreditation can be split into two parts.

Firstly, there is the actual cost of the accreditation process: this is the fees you will pay to the accreditation agency that certifies your practice has met the Standards. Your fees will include the accreditation program, survey visit, certification package, resources, and ongoing support throughout your practice's accredited period. Fees are calculated based on practice information, and will vary between accreditation agency and practice. When selecting an accreditation agency, it is recommended that you request information about the fees and inclusions as part of your decision-making process.

The second cost in relation to accreditation is the cost to your practice in achieving compliance. This may include purchasing necessary equipment, the cost of human resources to focus on accreditation preparation, the use of an approved commercial patient feedback survey provider, provision of required training (such as CPR), and other similar expenditure. However, all of these costs are, in fact, an investment in the quality of your practice.

It is also worth noting that most practices that achieve accreditation also participate in the Practice Incentives Program, providing them with additional income each quarter (assuming ongoing eligibility), while standard accreditation fees are only paid once every three years.

Who will visit my practice to assess it?

The survey visit is a peer review process. Surveyor team comprise of at least two surveyors, one of whom must be an appropriately qualified GP, and one of whom must be an an appropriately qualified nurse, practice manager, Aboriginal / Torres Strait Islander health worker, and occasionally an allied health worker. Surveyors must have current experience in an accredited general practice. On occasion, another person may accompany the surveyors, such as a non-health practitioner, a surveyor-in-training, or another healthcare support worker or consumer (your practice will give permission if a third party is to attend the visit).

It is important that surveyors have the relevant experience to enable them to survey your practices as peers. For this reason, the RACGP has set down clear guidelines for the requirements for surveyors. Accreditation agencies then provide training specific to the Standards and their own processes to support assessments that are based on common sense, and which foster collaboration and improvement by promoting the sharing of expertise among peers.

My practice has non-compliances: what does this mean?

A non-compliance is a finding that your practice has been unable to demonstrate that it meets an indicator in the Standards. A non-compliance does not mean you have failed the assessment: it means that you will be given the opportunity to act upon the finding and show how you will implement activities that will drive improvement in that area.

Non-compliances can be quite serious, or relatively minor. Serious non-compliances are those that place patient safety at risk. The Australian Commission on Safety and Quality in Health Care has set out a definition of significant risk, and a process for reporting such instances found during an onsite assessment. More information on significant risk can be found here.

Serious non-compliances will often relate to issues within medical records, lack of maintenance of clinical equipment, lack of process in appropriately storing and managing medicines (including vaccines), lack of process in managing test results, lack of robust handover systems, and other issues that compromise patient safety. These types of serious non-compliance will usually require implementation of long-term, quality improvement processes.

Minor non-compliances could include an insufficiently or incomplete documented process, lack of signage, omissions from key documents such as the practice information sheet, minor issues with physical aspects of the practice, or expired consumables (an issue which can often be addressed at the time of the visit by the disposal of the expired consumables). Another non-compliance commonly identified is the unavailability of documentation at the time of the visit. If your practice cannot show evidence, for example, that all staff have completed CPR training simply because the certificates are unavailable at the time of the visit, this will be marked as a non-compliance (and the certificates would then be submitted as corrective action after the visit).

It is worth noting that, when a practice is undergoing re-accreditation, your surveyors will usually review your practice's last accreditation assessment report prior to the onsite visit. In doing this, they will be able to identify the areas in which issues may have been identified in the last assessment, and whether the corrective actions have been implemented as planned, and have supported the necessary improvements.

Why does my accreditation agency want me to have my survey visit so early?

If non-compliances are found during the survey visit, a practice will need time to satisfactorily address the issue prior to its accreditation (or registration period, in the case of an initial accreditation) expiring. Accreditation agencies will usually try to leave three months between the survey visit date and the practice's expiry date to allow time for non-compliances to be addressed.

Practices will often ask to delay the survey visit until closer to the expiry date. This can put the practice under unnecessary pressure if there are significant, or a large number of, non-compliances found at the visit. It is often better to proceed to the survey visit and have time to address issues afterwards, than to delay the visit and assume that extra time will prevent non-compliances from being identified. Practices should work with their accreditation agency to keep to recommended timelines and seek support where required.

It is also important that practices understand that extensions to accreditation status cannot be granted by the accreditation agencies to practices that have not allowed sufficient time to complete the accreditation process within the time available.

Remember that, if your practice's accreditation expires, it will impact your eligibility for the Practice Incentives Program.

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